Appendix B3: Medical Evaluation Questionnaire for Asbestos Workers

This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos above the permissible exposure limit, and who will therefore be included in their employer's medical surveillance program. Part 1 of the appendix contains the Initial Medical Questionnaire, which must be obtained for all new hires who will be covered by the medical surveillance requirements. Part 2 includes the abbreviated Periodical Medical Questionnaire, which must be administered to all employees who are provided periodic medical examinations under the medical surveillance provisions of the standard.

Part 1INITIAL MEDICAL QUESTIONNAIRE

1. Name

____________________________________________________________

2. Social security number #

____________________________________________________________

3. Clock number

____________________________________________________________

4. Present occupation

____________________________________________________________

5. Plant

____________________________________________________________

6. Address - line1

____________________________________________________________

7. Address - line 2

____________________________________________________________

8. Telephone number

____________________________________________________________

9. Interviewer

____________________________________________________________

10. Date

____________________________________________________________

11. Date of Birth (Month/Day/Year)

____________________________________________________________

12. Place of Birth

____________________________________________________________

13. Sex

_____ Male

_____ Female

14. What is your marital status?

_____ Single

_____ Married

_____ Widowed

_____ Separated/Divorced

15. Race

_____ White

_____ Black

_____ Asian

_____ Hispanic

_____ Indian

_____ Other

16. What is the highest grade completed in school? ________________
(For example: 12 years is completion of high school)

OCCUPATIONAL HISTORY

17A. Have you ever worked full time (30 hours per week or more) for 6 months or more?

_____ Yes

_____ No

IF YES TO 17A:

B. Have you ever worked for a year or more in any dusty job?

_____ Yes

_____ No

_____ Does Not Apply

Specify job/industry ____________ Total Years Worked ________

Was dust exposure:

_____ Mild

_____ Moderate

_____ Severe

C. Have you ever been exposed to gas or chemical fumes in your work?

_____ Yes

_____ No

Specify job/industry _________________Total Years Worked ___

Was fume exposure :

_____ Mild

_____ Moderate

_____ Severe

D. What has been your usual occupation or job -- the one you have worked at the longest?(Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969)

Job occupation

____________________________________________________________

Number of years employed in this occupation

____________________________________________________________

Position/job title

____________________________________________________________

Business, field or industry

____________________________________________________________

Have you ever worked:

YES

NO

E. In a mine?

_____

_____

F. In a quarry?

_____

_____

G. In a foundry?

_____

_____

H. In a pottery?

_____

_____

I. In a cotton, flax or hemp mill?

_____

_____

J. With asbestos?

_____

_____

18. PAST MEDICAL HISTORY

YES

NO

A. Do you consider yourself to be in good health?

_____

_____

If "NO" state reason

________________________________________________________

B. Have you any defect of vision?

_____

_____

If "YES" state nature of defect

________________________________________________________

C. Have you any hearing defect?

_____

_____

If "YES" state nature of defect

________________________________________________________

D. Are you suffering from or have you ever suffered from:

YES

NO

a. Epilepsy (or fits, seizures, convulsions)?

_____

_____

b. Rheumatic fever?

_____

_____

c. Kidney disease?

_____

_____

d. Bladder disease?

_____

_____

e. Diabetes?

_____

_____

f. Jaundice?

_____

_____

CHEST COLDS AND CHEST ILLNESSES

19. If you get a cold, does it "usually" go to your chest? (Usually means more than 1/2 the time)

_____ Yes

_____ No

_____ Don't get colds

20A. During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed?

_____ Yes

_____ No

If "Yes" to 20A:

B. Did you produce phlegm with any of these chest illnesses?

_____ Yes

_____ No

_____ Does Not Apply

C. In the last 3 years, how many such illnesses with (increased) phlegm did you have which lasted a week or more?

_____ Number of illnesses

_____ No such illnesses

21. Did you have any lung trouble before the age of 16?

_____ Yes

_____ No

22. Have you ever had any of the following?

Attacks of bronchitis?

_____ Yes

_____ No

If "Yes" to A:

Was it confirmed by a doctor?

_____ Yes

_____ No

At what age was your first attack? Age in Years ______

Pneumonia (include bronchopneumonia)?

_____ Yes

_____ No

If "Yes" to B:

Was it confirmed by a doctor?

_____ Yes

_____ No

At what age did you first have it? Age in Years ______

Hay Fever?

_____ Yes

_____ No

If "Yes" to C:

Was it confirmed by a doctor?

_____ Yes

_____ No

C. At what age did it start? Age in Years ______

23.

Have you ever had chronic bronchitis?

_____ Yes

_____ No

If "Yes" to 23A:

Do you still have it?

_____ Yes

_____ No

Was it confirmed by a doctor?

_____ Yes

_____ No

At what age did it start? Age in Years ______

24.

Have you ever had emphysema?

_____ Yes

_____ No

If "Yes" to 24A:

Do you still have it?

_____ Yes

_____ No

Was it confirmed by a doctor?

_____ Yes

_____ No

At what age did it start? Age in Years ______

25.

Have you ever had asthma?

_____ Yes

_____ No

If "Yes" to 25A:

Do you still have it?

_____ Yes

_____ No

Was it confirmed by a doctor?

_____ Yes

_____ No

At what age did it start? Age in Years ______

If you no longer have it, at what age did it stop? Age stopped _____

26. Have you ever had:

Any other chest illness?

_____ Yes

_____ No

If "Yes", please specify:

____________________________________________________

Any chest operations?

_____ Yes

_____ No

If "Yes", please specify:

____________________________________________________

Any chest injuries?

_____ Yes

_____ No

If "Yes", please specify:

____________________________________________________

27.

Has a doctor ever told you that you had heart trouble?

_____ Yes

_____ No

IF "Yes" TO 27A:

Have you ever had treatment for heart trouble in the past 10 years?

_____ Yes

_____ No

28.

Has a doctor told you that you had high blood pressure?

_____ Yes

_____ No

IF "Yes" TO 28A:

Have you had any treatment for high blood pressure (hypertension) in the past 10 years?

_____ Yes

_____ No

29. When did you last have your chest X-rayed? _____________(year)

30. Where did you last have your chest X-rayed (if known)?

____________________________________________________

What was the outcome?

____________________________________________________

FAMILY HISTORY

31. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:

FATHER

MOTHER

1. Yes 2. No 3. Don't know

1. Yes 2. No 3. Don't know

A. Chronic Bronchitis?

__________

__________

B. Emphysema?

__________

__________

C. Asthma?

__________

__________

D. Lung cancer?

__________

__________

E. Other chest conditions?

__________

__________

F. Is parent currently alive?

__________

__________

G. Please Specify

_____ Age if Living
_____ Age at Death
_____ Don't Know

_____ Age if Living
_____ Age at Death
_____ Don't Know

H. Please specify cause of death:

____________________________________

___________________________________

(father)

(mother)

COUGH

32.

Do you usually have a cough? (Count a cough with first smoke or upon first going out of doors. Exclude clearing of throat.)(If no, skip to question 32C.)

_____ Yes

_____ No

Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week?

_____ Yes

_____ No

Do you usually cough at all on getting up or first thing in the morning?

_____ Yes

_____ No

Do you usually cough at all during the rest of the day or at night?

_____ Yes

_____ No

If "Yes" to any of above (32A, B, C, OR D), answer the following.
If "No" to all, check "DOES NOT APPLY" and skip to question 34A

Do you usually cough like this on most days for 3 consecutive months or more during the year?

_____ Yes

_____ No

_____ Does not Apply

For how many years have you had the cough? Number of years _____

33.

Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.)

_____ Yes

_____ No

(If no, skip to 33C)

Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week?

_____ Yes

_____ No

Do you usually bring up phlegm at all on getting up or first thing in the morning?

_____ Yes

_____ No

Do you usually bring up phlegm at all on during the rest of the day or at night?

_____ Yes

_____ No

If "Yes" to any of the above (33A, B, C, OR D), answer the following:

If "No" to all, check "Does not Apply" and skip to 34A

Do you bring up phlegm like this on most days for 3 consecutive months or more during the year?

_____ Yes

_____ No

_____ Does not apply

For how many years have you had trouble with phlegm? Number of years _____

Episodes of Cough and Phlegm

34.

Have you had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year?
* (For persons who usually have cough and/or phlegm)

_____ Yes

_____ No

If "Yes" to 34A:

For how long have you had at least 1 such episode per year?
Number of years _____

Wheezing

35.

Does your chest ever sound wheezy or whistling

When you have a cold?

_____ Yes

_____ No

Occasionally apart from colds?

_____ Yes

_____ No

Most days or nights?

_____ Yes

_____ No

If "Yes" to 1, 2, or 3 in 35A

For how many years has this been present? Number of years _____

36.

Have you ever had an attack of wheezing that has made you feel short of breath?

_____ Yes

_____ No

IF "YES" TO 36A:

How old were you when you had your first such attack? Age in years _____

Have you had 2 or more such episodes?

_____ Yes

_____ No

Have you ever required medicine or treatment for the(se) attack(s)?

_____ Yes

_____ No

Breathlessness

37. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 39A.

Nature of condition(s)

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

38.

Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill?

_____ Yes

_____ No

If "Yes" to 38A:

Do you have to walk slower than people of your age on the level because of breathlessness?

_____ Yes

_____ No

Do you ever have to stop for breath when walking at your own pace on the level?

_____ Yes

_____ No

Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level?

_____ Yes

_____ No

Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs?

_____ Yes

_____ No

Tobacco Smoking

39.

Have you ever smoked cigarettes? (No means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.)

_____ Yes

_____ No

If "Yes" to 39A:

Do you now smoke cigarettes (as of one month ago)

_____ Yes

_____ No

How old were you when you first started regular cigarette smoking?

_____ Yes

_____ No

If you have stopped smoking cigarettes completely, how old were you when you stopped?

Age stopped _____

Check if still smoking ____

Does not apply _____

How many cigarettes do you smoke per day now?

Cigarettes per day _____

Does not apply _____

On the average of the entire time you smoked, how many cigarettes did you smoke per day?

Cigarettes per day _____

Does not apply _____

Do or did you inhale the cigarette smoke?

Does not apply _____

Not at all _____

Slightly _____

Moderately _____

Deeply _____

40.

Have you ever smoked a pipe regularly? (Yes means more than 12 oz. of tobacco in a lifetime.)

_____ Yes

_____ No

If "Yes" to 40A: For persons who have ever smoked a pipe

How old were you when you started to smoke a pipe regularly? Age _____

If you have stopped smoking a pipe completely, how old were you when you stopped?

Age stopped _____

Check if still smoking pipe _____

Does not apply _____

On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week?

oz. per week ___ (a standard pouch of tobacco contains 1 1/2 oz.)

Does not apply ___

How much pipe tobacco are you smoking now?

oz. per week ___ (a standard pouch of tobacco contains 1 1/2 oz.)

Does not apply ___

Do you or did you inhale the pipe smoke?

Does not apply _____

Not at all _____

Slightly _____

Moderately _____

Deeply _____

41.

Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year)

_____ Yes

_____ No

If "Yes" to 41A: For persons who have ever smoked a cigar

How old were you when you started to smoke a cigar regularly? Age _____

If you have stopped smoking a cigar completely, how old were you when you stopped?

Age stopped _____

Check if still smoking cigars _____

Does not apply _____

On the average over the entire time you smoked cigars, how many cigars did you smoke per week?